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Prenatal Care Without Waiting Rooms?

I love that I have been able to experience childbirth from multiple vantage points. My first 3 pregnancies and births were with OB’s in a hospital setting. What I bring from that background is understanding, not judgment. I also experienced my first midwife/home birth journey alongside my sister, who was in her first pregnancy at the time with an OB. The differences in our care, time spent, information given and attention received were clearly noted for both of us the more we debriefed after each appointment. (So much so, that she elected to use a nurse midwife for baby #2 and had a home birth with baby #3!)

So, what does prenatal care with a midwife look like?

Please realize, like other healthcare providers, midwives aren’t all exactly alike. Appointments with me are generally one hour in length at my home office. There are exceptions of course, like the initial visit, which generally runs 90 minutes, the home visit, which may take just over an hour, and of course any circumstances that may arise which may necessitate extra time.

Why is this a big deal? Well, to be honest, I think that was my favorite part and the most noticeable difference between the medical model and the midwifery model of care. When I would have an OB appointment, though it may have taken an hour, that was including checking in, waiting in the waiting room to be called, using the bathroom/leaving a sample, having my vitals assessed by the nurse, waiting in the exam room, seeing my doctor/chatting for a few minutes, rescheduling my appointment with the front desk and finally walking to my car.

In contrast, when clients arrive for a midwifery appointment, there is little-to-no wait. The entire hour has been booked just for you! We start off with pleasant visiting conversation where I ask how you are (and I really care to know the answer!). I assess your vital signs, weight, nutrition, urine, any discomforts present, fundal height, baby’s position and fetal heart tones at each visit of course; but there is more to the whole person than those things alone.

I draw labs when needed throughout the pregnancy, typically at the initial visit, around 28 weeks and again at 36 weeks.  Prior to doing any of these tests I provide information and give the parents the opportunity for informed consent. (Another HUGE benefit of midwifery care).

Why so much time? I know, the idea may be so foreign as to be weird. I don’t hold anyone who has no need to be at her appointment longer than necessary. For some, they are done and ready to go within 30 minutes and that’s okay! But I want you to know that I allow a full hour and that we use that time to talk about what you’re going through, how you’re feeling, what’s coming up next and how to prepare. I believe the very foundation of midwifery care is wellness and prevention to work towards optimal outcomes.

Labor Support Services

I realize an out of hospital birth may not be an option for everyone; however, I feel you still deserve the best birth experience and support possible. As a result I also offer Doula/Monitrice Services.

What is a Monitrice?

A monitrice is similar to a doula with some added benefits. As a licensed midwife I am able to offer the extra services of monitoring your baby’s heart rate, taking your vital signs and performing cervical exams (if requested) to help ascertain the appropriate time to head to the hospital so that you can enjoy the comfort of your home in that early stage of labor.

Support for Hospital Births

Generally this option includes 1-2 prenatal visits, labor support for the birth itself and a follow up postpartum visit.

I will:

  • Perform vital sign assessments on mom upon arrival and at regular intervals throughout labor until it is time to head to the hospital for delivery.
  • Perform internal (cervical) exams, if requested (using sterile technique).
  • Monitor baby’s heart rate every half hour, or as needed, starting on arrival.
  • Assist mom in various ways throughout her labor including relaxation, positioning, comfort
    techniques, encouragement and support.
  • Answer questions and help inform when inquiries are made once we are at the hospital.
  • Remain for 1-2 hours following delivery and assist with the initial breastfeeding experience, if
    desired.

I will not:

  • Take the place of your partner or other labor support.
  • Act as your healthcare provider.
  • Knowingly attend an unplanned home birth.

Common Pregnancy Discomforts

Backache

Pain located in the upper or lower segments of the back.

It is common to experience some aches and pains in the upper or lower regions of the back because of the anatomic changes occurring during pregnancy. Enlarged breasts and a growing uterus contribute to a change in weight and the center of gravity. Add to this poor posture, inadequate muscle tone and an exaggerated curve of the lower back (lordosis). Aggravating factors include a posterior fetal position, standing in place for too long and bending forward at the waist.

Carpal tunnel syndrome

Altered sensations, including tingling, numbness, pain, stiffness and weakness in the thumb, index, middle and radial portion of the ring finger that can travel upwards affecting the arm and shoulder.

While carpal tunnel syndrome can exist outside of pregnancy from repetitive hand/wrist movements (typing), the weight gain, fluid retention from hormones and subsequent swelling during pregnancy sometimes compress the medial nerve in the wrist.

Constipation

Infrequent and/or difficult eliminations as stools become hardened and back up within the intestinal tract.

Although it is not considered normal, constipation in pregnancy commonly occurs as a result of the hormone progesterone and its relaxing effect on the peristalsis of the stomach and intestinal tract. The additional transit time allows more water to be absorbed in the intestines. A poor diet, iron supplements and the pressure of a growing uterus, which displaces the organs beneath, also contribute to constipation.

Dyspareunia

Painful sexual intercourse.

Physical changes in pregnancy, abdominal growth and a descended baby can cause vaginal crowding and impaired circulation. Emotional concerns of fear regarding trauma to the baby can also play a role in dyspareunia.

Edema

Swelling of the lower body extremities, legs and ankles (can include fingers) evidenced by indentations (from footwear/socks) with possible feelings of tightness.

Swelling can be caused by a variety of reasons. Typically the more common reason is due to the normal, healthy expansion of blood volume and hormones. Other causes can be diet related (not enough salt, fluids and/or protein), duration of standing/sitting and increased perspiration.

Fatigue

Drained, sluggish and general feelings of tiredness. 
(extremely common in 1st trimester)

It is common for women in their first trimester to experience fatigue as their bodies adjust to new demands and hormone fluctuations. Fatigue can also be related to a decreased basic metabolic rate, hypoglycemia, anemia, emotional stress and multiple gestation.

Headache

Sharp, dull, throbbing or steady pain located in the front, back or sides of the head.

A headache can be caused from dehydration, hypoglycemia, anemia, eye strain, exposure to toxins, exposure or recent withdrawal from caffeine & sugar and vasodilation of the blood vessels due to poor tone.

Heartburn

Burning sensation in esophagus due to reversed peristalsis.
(may be felt in chest or neck)

Progesterone, a pregnancy hormone, affects the cardiac sphincter (top opening) of the stomach by relaxing it and decreasing the movement of the stomach, which prolongs the emptying time. This issue combined with the effects of a growing uterus that pushes and displaces the stomach cause digestive fluids to enter the lower esophageal tract causing an uncomfortable, burning sensation.

Hemorrhoids

Though hemorrhoids can be present without pain, the abnormal dilation of veins located in cushions around the anal sphincter can also protrude, swell, itch and become noticeably painful.

Hemorrhoids are most often caused by constipation, so many of the factors that lead to difficult bowel movements can therefore also be tied to this discomfort. Additional contributors include standing for prolonged periods, weakened blood vessels, lack of venous valves, pooling of blood from backflow during abdominal pressure (such as repeated straining from constipation), progesterone’s effects of relaxing vein walls and poor circulation from the increased pressure of the growing uterus.

Insomnia

Sleeplessness or difficulty falling asleep.

Mentally it may be difficult to get good sleep because the mind is racing with thoughts, concerns, anxieties and/or anticipation! Physically, insomnia could be due to hypoglycemia, deficient intake of B vitamins, discomfort with growing uterus or an active baby.

Leg Cramps

Sudden pain causing a tight pulling sensation in the leg.

Leg cramps can occur because of deficiencies in the diet, including inadequate salt intake. While there is evidence that too little sodium, calcium, magnesium, potassium and phosphorous can be responsible, it is interesting to note that excess calcium has also been attributed to leg cramps. Additionally, the weight of the growing baby and uterus exert pressure on veins and nerves from the pelvis running below, which contribute to the possibility of leg cramps.

Nausea & Vomiting

Common between 4-14 weeks of pregnancy, this queasy unsettled feeling, which may or may not include vomiting, can occur at any time of day or persist throughout the entirety of the day.

Various influences can be attributed to the nausea and vomiting experienced by 1/2 to 2/3 of pregnant women. In the first trimester the influx of hormones, such as estrogen and HCG (human chorionic gonadotrophin), along with their concentration as the blood volume has not yet expanded can negatively affect some women. In addition, changes in dietary needs versus intake, decreased blood sugar and conflicting emotions have been linked to nausea and vomiting as well. Late in pregnancy, nausea & vomiting can be caused by the increasing pressure and discomfort from the growing uterus.

Pruritis gravidarum

Intense itching, usually occurring in the third trimester, can begin on the abdomen and spread generally all over; form of jaundice in pregnancy.

The increased amount of hormones, estrogen and progesterone can effect the liver’s ability to excrete bile salts. As this condition is related to the liver, it can also occur if the liver has been compromised because of other circumstances not related to hormones.

Round ligament discomfort

Can be described as a sharp pulling pain or cramp, felt on one or both sides of the uterus extending into the pelvic area (or solely occurring there).

The round ligament is made to stretch with the uterus; therefore as it grows the stretching and pulling itself can be uncomfortable. Pressure from the enlarging uterus in addition to the frequency of contractions toward the end or pregnancy, make triggering this spasm more likely.

Sciatica

Irritation of spinal nerve, felt from the hip area to the back of the upper leg, described as sharp pain, tingling or weakness.

The sciatic nerve is the longest nerve in the body and runs from the lower spine down through the back of the thigh. Because it runs through an opening in the pelvis, pregnancy, more specifically the growing uterus, causes shifting that can impede or encroach on this nerve causing irritation and radiation of the pain.

Varicosities

Dull aching pain from enlarged blood vessels, typically located in the legs or vulva.

Varicosities can occur because of the combination of expanded blood volume and the relaxing effect of progesterone. Lack of vein wall tone and weakened valves from the lower extremities compete with the increased blood flow from the uterus. In addition, family history of varicosities can contribute to a person’s likelihood of developing the condition.

References

Davis, E. (2004). Heart & hands (4th ed.). Berkeley, CA: Celestial Arts.

Frye, A. (2008). Holistic midwifery: A comprehensive textbook for midwives in homebirth practice (Vol. 1). Portland, OR: Labrys Press.

Myles, M. F. (1975). Textbook for midwives with modern concepts of obstetric and neonatal care (8th ed.). London, UK: Churchill Livingstone.

Parker, S. (2008). The naturally healthy pregnancy: Whole health for your whole pregnancy. Calhoun, LA: Dewdrop Publishing.

Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varney’s midwifery (4th ed.). Sudbury, MA: Jones and Bartlett Publishers.

 

Exercise

Exercise

Women in a low risk pregnancy are highly encouraged to stay active. Pregnancy is not the time however to start up a new or more rigorous activity. If you were pretty active prior to getting pregnant you are better prepared to continue that activity (with your doctor/midwife’s approval). Walking is always a great choice as it is low impact and can be started at any time (and is encouraged throughout pregnancy)!

When exercising it is important to remember your body is changing and the hormones of pregnancy can cause you to be less balanced. (Watch those activities that require a lot of coordination!)

It may be helpful to borrow or invest in a heart rate monitor so that you can be sure you aren’t exceeding your target heart rate for extended periods of time and know when to back down.

Nutrition

Nutrition

USDA Health and Nutrition for Pregnant & Breastfeeding Women

Quick Tips:

  • Be sure you’re getting enough protein each day! (Snacks should contain protein too, not just meals!)
  • Eat small amounts of food more frequently (at least every 3 hours) to avoid drops in blood sugar.
  • Watch portions! You’d be surprised that “eating for 2” doesn’t equate to as many calories as you would think. On average, depending on your activity level, most women only need an extra 300 calories per day in pregnancy.
  • Stay hydrated by drinking enough water!
  • You’re growing a human being, eat a variety of fresh, whole foods to get adequate nutrients!

 

 

Postpartum Care: When to Call

Symptoms: Baby

If any of the following are noted, please call your midwife immediately for further instruction/information!

Respirations

  • Fewer than 30 or greater than 70 breaths per minute while resting.
  • Labored breathing with grunting, retracting of the ribs or abdomen or flaring of the nostrils.
  • Apnea: not breathing for 20 seconds or longer, especially with color changes.

Heart Rate

  • Heart rate less than 110 or greater than 160 at rest
  • Color changes associated with changes in heart rate

Color

  • Any blue or dusky color located on the face or trunk
  • Jaundice or yellow color is abnormal if it occurs in the first 24 hours and your baby should be seen immediately
  • If your baby is lethargic, feeds poorly, has excessive weight loss, temperature instability, dark urine, light colored stools or persistent jaundice

Temperature

  • Axillary temperature of less than 96.8 or greater than 99 after clothing and room temperature have been adjusted.
  • Or if baby’s temperature fluctuates a lot even when room temperature and clothing remain the same.

Elimination

  • No passage of stool or urine in the first 24 hours after birth.
  • Bloody or excessively watery stools that are a change
  • Blood or rusty color in urine esp after the third day

Other signs

  • Excessive sleepiness- sleep periods longer than 6 hrs after the first day.
  • Hyperirritability or extreme reaction to ordinary activities like diaper changes or picking him up.
  • Poor feeding, not at all interested in feeding or exhausted by it.
  • Regular projectile vomiting
  • Bile-stained vomit
  • Poor muscle tone – “Spread Eagle Positioning”
  • Taut, swollen abdomen
  • Cord Issues
    • Yellow, green or blood is noted at the base of the cord
    • There is a foul odor coming from the cord
    • There is redness or warmth around the base of the umbilical cord

Symptoms: Mom

If any of the following are noted, please call your midwife immediately for further instruction/information!

Temperature

  • Fever above 100.4 after drinking lots of fluids.

Pulse

  • Greater than 100 beats per minute while resting, occurring twice in 1-2 hours. Call your midwife immediately if accompanied by heavy bleeding.

Uterus

  • If it remains soft, does not respond to massage and heavy bleeding is occurring.

Lochia

  • Heavy bleeding, soaking a large pad completely in less than 2 hours after the first 24 hours.
  • Passage of tissue or fowl-smelling discharge.
  • Persistent passage of clots larger than a lemon.

Signs of mastitis

  • Pain lasts longer than 48 hours
  • Fever of 101 degress or higher
  • You have a hot, red, tender area on your breast
  • Difficulty nursing
  • Chills or flu-like symptoms

Infection

  • You are not able to urinate
  • You experience pain or burning with urination
  • You experience urgency
  • Your urine has a foul odor
  • Temperature of 101 degrees or greater

Other signs

  • Fainting
  • Severe headache, blurred vision, just feeling bad, hazy feeling, aura
  • Severe pain in abdomen, chest or legs
  • Shortness of breath
  • Feelings of despair, great anxiety or inability to cope